RABIES

(Hydrophobia/Lyssa)

Definitions
Rabies is a specific, acute viral infection

communicated to man by the saliva of an infected animal. (Dionesa Mondejar-Navales) An acute infectious CNS disease with fatal outcome; transmitted to humans by bite of rabid animals like dogs, foxes and cats. Bats, foxes and raccoons serve as reservoir of infection. (medical dictionary)

CENTRAL NERVOUS SYSTEM

Etiologic Agent
Rhabdovirus

1. It is a bullet-shaped filterable virus with a strong affinity for the CNS. 2. The organism is sensitive to sunlight, ultraviolet light, ether, formalin, mercury and nitric acid. It is resistant to phenol, merthiolate and common antibacterial agents

Incubation Period
1. 1 week-7 months in dogs 2. 10 days to fifteen yrs in human 3. Incubation period depends on the following factors: a. distance of the bite to the brain

b. extensiveness of the bite c. species of the animal d. richness of the nerve supply in the area of the bite e. resistance of the host

Period of Communicability

The patient is

communicable from 3-5 days before the onset of symptoms until the entire course of illness.

Mode of Transmission
An infected animal carries the rabies virus in

its saliva and transmits it to humans by biting. In some cases, the virus is spreads from the saliva comes in contact with the persons mucus membrane, such as those with the mouth and eyelids, or broken skin, like in cuts, scratches or open wounds.

Pathogenesis
1. From the site of the bite, the organisms proceeds to the CNS through the exoplasm of

the peripheral nerves. 2. Experimental studies have shown that the virus stays for some time in the inoculation site and that the multiplication of the virus occurs in the myocytes. 3. It has been observed that the period between inoculation and nerve invasion is the only time when prophylactic vaccine is effective.

4. Once the virus infects the individual, the spread is both centripetal and centrifugal. 5. After infection of the CNS, the virus spreads through the peripheral nerves to the salivary glands and other organs, such as the lungs, adrenals, kidneys, bladder and testicles (priapism)

Pathology
1. The rabies virus causes widespread changes throughout the CNS. 2. Histologic findings include neural necrosis and mononuclear cellular infiltration, especially in the thalamus, hypothalamus, pons and medulla. 3. The cranial nerve nuclei are extensively damaged. 4. Neural changes are present in the spinal cord, especially in the posterior horn. 5. Negri bodies are most abundant in the hypocampus, basal ganglia, pons and medulla and are found in the degenerating neurons of the salivary glands (pathologic sign for rabies)

Clinical manifestations (3 phases)

1. Prodromal /Invasion phase

a. The phase is characterized by fever, anorexia, malaise, sore throat, copious salivation, lacrimation, perspiration, irritability, hyper excitability, apprehensiveness, restlessness, (drowsiness) sometimes, mental depression, melancholia and marked insomnia. b. There is pain at the original site of the bite. Headache and nausea may be present.

c. The patient becomes sensitive to light, sound and temperature. d. there are pain and aches in different partsw of the body. e. Anesthesia, numbness, and tingling, burning and cold sensations may be felt along the peripheral nerves involved and the site of the bite. f. Mild difficulty in swallowing.

2. Excitement or neurological phase

a. This phase is characterized by marked excitation

and apprehension . Terror may even occur. b. There is delirium associated with nuchal rigidity , involuntary twitching or generalized convulsions. c. The patient may exhibit maniacal behavior; eyes are fixed and glossy and the skin is cold and clammy. d. . There are severe and painful spasm of the muscles of the mouth, pharynx and larynx on attempt to swallow water or food or even at the mere sight of them.

e. There is aerophobia or intense fear or dislike of air. f. There is profuse drooling g. There are tonic or clonic contractions of the muscles. h. Death may occur during episode of spasms or from cardiac/respiratory failure. i. If patient survives this phase, h/she deteriorates rapidly and enters the terminal phase.

3. Terminal/Paralytic Phase
a. The patient becomes quiet and unconscious. b. There is loss of bowel and urinary control. c. Spasms cease and there is progressive

paralysis. d. There is tachycardia and labored irregular respiration. e. Death occurs due to respiratory paralysis, circulatory collapse or heart failure.

Diagnostic Procedure
1. Virus isolation from the patients saliva or

throat. 2. Fluorescent rabies antibody (FRA) provides the most definitive diagnosis. 3. Presence of Negri bodies in the dogs brain

Modalities of Treatment
Thoroughly wash the wounds from the bite and scratches with soap and running water for at

least 3 minutes Check the patients immunization status. Give tetanus toxoid if needed. Give tetanus antiserum infiltrated around the wound or intramuscularly after a negative skin test. Give anti-rabies vaccines, both passive and active, depending on the site and size of the bite, as well as the health condition of the biting animal.

Nursing Management
isolate the patient. Give emotional and spiritual support Provide optimum comfort and prevent injury,

esp during hyperactive episodes. Darken the room and provide a quiet environment. The patient should not be bathed and there should not be any running water in the room or within the hearing distance of the patient.

 If IV fluid has to be given, it should be

wrapped. The needle should be securely anchored to the vein to avoid dislodging in times of restlessness. Concurrent and terminal disinfection should be carried out.

Common nursing diagnosis

Altered nutrition: Less than body

reqiurement Fluid volume deficit Anxiety Knowledge deficit Altered thought process Anticipatory grieving

Prevention and control

The eradication of rabies should be done on global scale and should include measures to prevent and control the disease in animals. The primary preventive measure in rabies is the interruption of the mode of transmission. Specific steps include: 1. vaccination of all dogs; 2. enforcement of regulation for the pick-up and destruction of stray dogs; 3. ten-to-fourteen-day confinement of any dog that has bitten a person.

4. Availability of laboratory facilities for observation and diagnosis; and 5. Providing public education, especially to children, on the avoidance and reporting of all animals that appear sick

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